A pressure ulcer, also called a pressure injury or bedsore, is damage to the skin and the tissue underneath caused by pressure, often combined with shear. It usually develops over bony areas such as the sacrum, heels, hips and elbows, and can form within hours in a high-risk patient. Most pressure ulcers are preventable.
Pressure injury stages
| Stage | What you see |
|---|---|
| Stage 1 | Intact skin with a localised area of non-blanchable redness. The area may feel painful, firm, soft, warmer or cooler than nearby skin |
| Stage 2 | Partial-thickness skin loss with exposed dermis: a shallow pink or red wound bed, or an intact or ruptured blister |
| Stage 3 | Full-thickness skin loss. Fat may be visible; slough or eschar may be present, but no bone, tendon or muscle is visible |
| Stage 4 | Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone |
| Unstageable | Full-thickness loss where the base is hidden by slough or eschar, so the depth cannot be seen |
| Deep tissue pressure injury | Intact or broken skin with a persistent deep red, maroon or purple area, or a blood-filled blister, from damage deep in the tissue |
Pressure ulcers can also be caused by medical devices such as oxygen masks, tubing, splints and catheters, and can develop on mucous membranes.
Assessing darker skin tones
Redness can be hard or impossible to see on darker skin. Look for colour changes compared with surrounding skin (purple, blue or darker areas), and feel for warmth, coolness, firmness, swelling or pain. Good lighting and asking the patient about soreness help. Never record “skin intact” just because you cannot see redness.
Prevention: the SSKIN bundle
| Letter | Action |
|---|---|
| S – Surface | Use the right mattress and cushion for the patient’s risk level, and check it works |
| S – Skin inspection | Check all pressure areas and under devices at least at every repositioning |
| K – Keep moving | Reposition regularly; support people who can move to do so themselves |
| I – Incontinence and moisture | Clean promptly, use barrier products, and manage sweat and wound fluid |
| N – Nutrition and hydration | Screen for malnutrition, offer fluids, and refer to a dietitian when needed |
How often should patients be repositioned?
UK NICE guidance suggests adults at risk should be repositioned at least every 6 hours, and those at high risk at least every 4 hours, with more frequent changes based on skin checks. Use a 30-degree tilt, keep the head of the bed as low as is safe to reduce shear, and float the heels off the mattress.
Risk assessment
Use a validated tool your facility recommends, such as Braden, Waterlow or PURPOSE-T, on admission and when the patient’s condition changes. Risk factors include immobility, previous pressure damage, poor nutrition, incontinence, diabetes, poor circulation and reduced sensation.
Caring for an existing ulcer
- Stage and measure it, photograph it if allowed, and record it on a body map
- Relieve pressure from the area completely
- Clean and dress according to the wound’s needs; see our diabetic foot care checklist for heel care
- Manage pain before dressing changes
- Refer stage 3, stage 4, unstageable and deep tissue injuries to the tissue viability team
- Report it according to your local incident policy
Sources: National Pressure Injury Advisory Panel (NPIAP) staging definitions; NICE clinical guideline CG179, Pressure ulcers: prevention and management; NHS England, SSKIN care bundle; International guideline on pressure injury prevention and treatment (EPUAP/NPIAP/PPPIA, 2019).
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